The old age sufferer's diabetes treatment老年患者的糖尿病治疗

Because mankind's life span continuously extension, the diabetes can be valid the controller can have with the longevity of can live 85 years old above.But 60 years old enter person old age period become sick can also because of control more bad but occurrence severity complications early Wu.Therefore, diabetes of treatment shouldn't be subjected to age limit, should with medium youth similar aggressive treatment, blood sugar control at normal or close normal level, and make it long-term to keep bottom.
Someone think the old people's life span again not long, don't need to be cure, even at the blood sugar very Gao also don't adopt aggressive measure.This is wrong.So not only will make chronic complications(the heart cerebral disease, kidney pathological changes, nerve pathological changes) acceleration development, and also can cause severity of impatient complications(Gao Shen collapsed and fainted, the Tong disease be sour poisoned), invite to die.
But want to notice, carry on to the old age diabetic valid of control often have low blood sugar reaction.The low blood sugar endanger bigger to the old people, so to old age diabetes of treatment since want to attain better of control blood sugar, again want to prevent°from low blood sugar reaction.Our experience is to adopt to loosen a treatment project, will soon empty stomach blood sugar control below 8 mmol/L, the after meal 2 hours blood sugar control below 12 mmol/L is standard.Rightness more long time after the food therapy, empty the stomach blood sugar is in the 8 mmol/L above, the after meal 2 hours blood sugar have never declined to a 12 mmol/L the following, and strengthen athletics therapy can not also attain treatment effect of old age Ⅱ type diabetic, can take orally to decline a sugar medicine, concrete treatment measure as follows:
1.food therapy
The food control is a diabetes the foundation of the treatment.Old age have 30% sufferer a demand around in the diabetic pure of food therapy then control.The principle of food therapy is:
(1)since want a food control, want nourishment again ample with keep ideal weight.Old age everyday of diabetic total the calories card can press each kilogram weight 30 cards be or so estimate.Protein each kilogram weight 1.0-1.5 gram, demand Gao egg white can Gao some.Everyday of carbohydrate is 200-300 grams.(staple food 4-6 two)The fat want just the right amount of control to contain saturation shoot of fatty acids person.
(2)fat everyday of total the calories card want to be a little bit low, for the convenience of after gradually reduce weight, attain ideal weight the sugar bear quantity to usually show Zhao improvement.Lower total hot the card be gradual decrease weight and can press to say formula:Total calories card-250 card+30 minutes activity=gradual decline a weight. (3)the old people's food habit hard change, food treatment should press condition, life habit, physical strength consume and economy the condition be individual establishment.Should make patient ability full comprehension food control of importance combine ability active match oneself control.
(4)have Gao Zhi Xie3 the disease to the companion, control according to the blood fat's circumstance, increase Gao Zhe3 such as the cholesterol should be to the low cholesterol food;To Gao glycerin two fat, should with strict restriction carbohydrate is lord.
(5)to application the one who decline sugar medicine, the food want to adapt at the medicine treatment, especially use the sufferer of insulin treatment, everyday be divided into at least four eat for meal, then add a meal once before sleep.
2.sport rapy
Sport can lower blood sugar, ability improvement cardiovascular condition, lower blood pressure, blood fat, again improvement mental state appearance.But sport rapy can't act precipitately, should with light degree activity beginning, according to bear the ability of be subjected to gradual increment activity quantity, but don't exceed heart lung and the bear of joint ability of be subjected to.
3.take orally medicine therapy
Take orally to decline a sugar medicine to have 2 types currently:
1 type decline a sugar medicine for the Huang Mao, this medicine main function pass to stimulate B cell in the Yi island to secrete insulin, return can increment liver sugar original of storage and increment organization take glucose, but make the blood sugar descend.The generation Huang Mao representative the medicine is a D860, this kind medicine almost complete is eject by the kidney, old people's obsolescent, especially haven't whole kidney function the old man to forbid to use;In recent years the Mao medicine of the next generation Huang already successive publish, such as excellent decline sugar and reach the United States Kang, the United States Mao Da, gram the sugar benefit, sugar kidney be equal.The characteristics of this kind medicine include:
The ① function is strong, the amount of be small, and the side effect be low.
② And is cholesterol-lowering, the improvement blood flow to change to learn and is certain to keep capillaries pathological changes from etc. a function.
③ Sugar kidney even 95% be eject by the Dan way, application at the old people especially the companion hasn't whole kidney function the most suitable use.But excellent decline sugar 50% is eject by the kidney, and easy cause low blood sugar reaction, old age sufferer application hour should close observation.
I am another to decline a sugar medicine for the double Gua:This medicine main function is to pass to repress a bowel way a recovery glucose with promote the glucose is in the organization resolve but have already declined a sugar function, often have digest way reaction, it representative medicine for decline sugar to work properly, decline a sugar slice, two Gua etc..Because this kind medicine side effect obvious, some nation already not produce.But according to local experience, reasonably application curative effect still quite good of, side effect can also decrease, particularly that the side effect which decline a sugar slice be weaker than to decline sugar to work properly, function also ratio decline sugar to work properly weak.
4.insulin therapy
(1)application insulin of advertise for:Old age diabetes above 95% is a non- insulin the Ⅱ type of the dependence diabetes, general say come not demand insulin treatment, but clinical have around 20% of old age diabetic food therapy and take orally to decline sugar medicine to have no command over, but demand use insulin treatment.Old age diabetic application insulin be advertise for as follows:
A diabetic of① insulin dependence.
The disease of ② Tong is sour poisoned or Gao Shen collapsed and fainted of diabetic.
The ③ take orally to decline sugar medicine the Ⅱ type of the expiration diabetic.
The ④ merger infection, wound, big surgical operation, cerebral accident, the myocardial infarction, mental exertion crock up etc. should intense emotion condition, even originally take orally to decline a sugar medicine to contain good effect, also want temporarily usage insulin treatment.
The ⑤ food therapy have no command over, again not proper application take orally the diabetic of the Ⅱ type of decline the sugar medicine.
(2)the method of application insulin:Normal person everyday secrete 24-48 unit insulin, past insulin of application the amount of want to be low here standard is proper, because the insulin of diabetic secrete just opposite or absolute shortage.Under the condition that strict food control, general urine the sugar(+) add to use insulin 4 units, the blood sugar be each Gao in normal 50 mg/dL(2.98 mmol/L) increment insulin 2-3 unit.Such as food control of not good or don't control food, insulin quantity should basis circumstance increment, short effect with long effect insulin of ratio is 2:1, everyday three quantity allotment is:Breakfast front>dinner front>lunch front.When blood sugar urine the sugar be close normal, insulin quantity should be partial to small(press above-mentioned standard subtract 1/2-1/3), so would safety some.If after meal blood sugar Gao, choose to use short everyday of effect insulin 3 times or medium effect insulin everyday 1-2 times;If empty stomach blood sugar also Gao, can early or late add to use long effect insulin.Inject time general at meal the first 15-30 minute, old age sufferer should attention nighttime low blood sugar disease.
(3)condition monitor and control standard:Application insulin of condition monitor the item be main to have urine Tong body, empty stomach blood sugar, the after meal 2 hours, blood sugar, the diabetes"three many" symptom and low blood sugar disease.
Application insulin of condition control standard, currently domestic still have never unify provision.1994 Pacific Asia region provision of standard is empty stomach blood sugar<7.8>145 mmol/L, carry on sex consciousness obstacle companion severity dehydrate, Tong body feminine gender or weak masculine gender, then diagnosis.
(1)quick repair a liquid:When blood sodium>145 mmol/L, the blood plasma permeate to press the ≥ 320 mosm/L(the blood plasma permeate to press estimate formula:2(Na+K)+the blood sugar mmol/L)hour, lose a life reason brine, repair the amount of liquid can first press weight 10%-15% estimate juice, the first 4 hour repair person's total amount of 1/2, rest finish lose in 24 hours, in totally the liquid should have 400- 800 ml blood plasma, the low mark son is right Xuan sugar the Hang may also be advantageous to maintenance blood pressure and prevent°from brain dropsy.
(2)small quantity insulin:The short 4-6 u/h of the effect insulin is a little bit quiet and be blood sugar to decline to a 14 mmol/L, can use glucose or glucose brine(insulin and glucose comparison is 1 u:4 g), measure blood sugar once every 2-4 hours in the treatment process.Such as use a big quantity insulin, make blood sugar and blood plasma permeate to press down to once decline quick, then can make water quick toward the cell inside transfer, but cause brain dropsy, shock impatient the kidney function crock up, low blood sugar etc..
(3)be little for sufferer's 4-6 hourses urine or have no urine, should in consideration of occurrence the kidney function be not whole, can give soon urine.
(4)the aggressive treatment induct disease, companion hair disease and complications, especially infection and the electrolyte mess, mental exertion crock up, the kidney function be not whole and cerebral accident etc.. 6.the diabetes lactic acid be sour poisoned of treatment
This complications is more seldom seen, but when old age Ⅱ type the diabetic get severity of cardiovascular disease, kidney disease or lung disease sufferer, because of heart row the amount of blood lower, the blood pressure descend, organization anoxia appearance bottom, appear breath deep quick, consciousness misty, collapsed and fainted, blood pH<7.35,>5 mmol/L, urine Tong body feminine gender, then diagnosis.
(1)remove to induct a factor:Immediately stop using a pair of Gua to decline a sugar medicine to rectify organ function, improvement anoxia, aggressive nti- infection.
(2)rectify sour poisoned:Lose 5%250-500 ml of the baking soda of person, lose amount of person to see blood pH a circumstance but settle.In the meantime should complement the physiology brine rectify dehydrate.
(3)insulin treatment:Blood sugar>17 mmol/L, a little bit quiet 4-6 u every 2-4 hours insulin;Blood sugar<11>晚餐前>午餐前。当血糖尿糖接近正常时，胰岛素剂量应偏小(按上述标准减去1／2-1／3)，这样会安全些。若餐后血糖高，选用短效胰岛素每日3次或中效胰岛素每日1-2次；若空腹血糖也高，可在早或晚加用长效胰岛素。注射时间一般在餐前15-30分钟，老年患者应注意夜间低血糖症。
　　(3)病情监测及控制标准：应用胰岛素时的病情监测项目主要有尿酮体、空腹血糖、餐后2小时血糖、糖尿病“三多”症状及低血糖症。
　　应用胰岛素时的病情控制标准，目前国内尚无统一规定。1994年亚太地区规定的标准是空腹血糖<7．8mmol／l，餐后2小时血糖<11．1mmol／l及消除糖尿病症状。应当注意的是对老年糖尿病的控制标准松一些为宜，我们多年来临床经验认为老年糖尿病人血糖控制标准，以空腹血糖<8mmol／l，餐后2小时血糖<12mmol／l为宜。因为老年人不像年轻人那样能耐受低血糖。>145mmol／L，进行性意识障碍伴严重脱水，酮体阴性或弱阳性，即可诊断。
　　(1)迅速补液：当血钠>145mmol／L，血浆渗透压≥320mosm/L(血浆渗透压估计公式：2(Na+K)+血糖 mmol／L)时，输人生理盐水，补液量可先按体重10％—15％估汁，前4小时补人总量的1／2，其余在24小时输完，在总液体中应有400— 800ml血浆，低分子右旋糖酐亦可，有利于维持血压及防止脑水肿。
　　(2)小剂量胰岛素：短效胰岛素4—6u／h静点，当血糖降至14mmol／L时，可用葡萄糖或葡萄糖盐水(胰岛素与葡萄糖比例为 1u：4g)，在治疗过程中每2-4小时测血糖1次。如用大剂量胰岛素，使血糖及血浆渗透压下降过快，则可使水迅速向细胞内转移，而导致脑水肿、休克急性肾功能衰竭、低血糖等。
　　(3)当患者4—6小时少尿或无尿时，应考虑到发生了肾功能不全，可给速尿。
　　(4)积极治疗诱发疾病、伴发疾病及并发症，特别是感染以及电解质紊乱、心力衰竭、肾功能不全、脑血管意外等。　　　　6．糖尿病乳酸性酸中毒的治疗
　　此并发症比较少见，但当老年Ⅱ型糖尿病人患有严重的心血管病、肾脏疾病或肺疾患者，由于心排血量降低、血压下降、组织缺氧状态下，出现呼吸深快、意识模糊、昏迷、血pH<7．35，血乳酸>5mmol／L、尿酮体阴性时，即可诊断。
　　(1)除去诱发因素：立即停用双胍类降糖药纠正器官功能，改善缺氧，积极抗感染。
　　(2)纠正酸中毒：输人5％碳酸氢钠250-500ml，输人量视血pH情况而定。同时应补充生理盐水纠正脱水。
　　(3)胰岛素治疗：血糖>17mmol／L，每2—4小时静点4-6u胰岛素；血糖<11mmol／L，在静脉滴人胰岛素同时输人5％葡萄糖液，防止低血糖。
　　(4)纠正电解质紊乱：特别在应用胰岛素情况下，注意补钾。
　　(5)血压下降时，给升压药，宜用多巴胺、阿拉明等对微循环和肾血流量影响小的药物。
　　7．糖尿病酮症酸中毒的治疗
　　(1)胰岛素治疗：胰岛素是治疗糖尿病酮症酸中毒的关键。因为胰岛素不仅能增加葡萄糖利用，还能抑制游离脂肪的释放，抑制游离脂肪酸在肝内转变成酮体，所以糖尿病酮症酸中毒病人，应首选胰岛素治疗。关于胰岛素的应用方法，近年来的研究证实，治疗糖尿病酮症酸中毒，以小剂量普通短效胰岛素4— 6u／h肌注或静脉点滴具有与大剂量同样的效果，而且可以减少低血糖、低血压、脑水肿、肾功能衰竭等并发症的发生。如果胰岛素人液体治疗6小时，血糖水平仍不下降，则应考虑可能有胰岛素抵抗，可将每小时胰岛素剂量加倍，直到血糖降至13-14mmol/L，然后改用5％葡萄糖盐水或5％葡萄糖液加胰岛素治疗之。
　　(2)补充液体：由于高血糖、高酮体所引起的高渗透性利尿失水，及水摄人量少，加之呕吐、腹泻等所致的脱水，应静脉补给生理盐水、消化道补水，当血糖降至13—14mmol/L时，可用5％葡萄糖液静脉输人，至于补液多少及补液速度应根据患者的脱水程度、心脏情况及年龄而定。在补液同时应注意纠正电解质平衡。
　　(3)抗感染：老年糖尿病酮症酸中毒常常在感染等应激情况下诱发，因此积极进行抗感染治疗。